Basic Information
| Provider Information | |||||||||
| NPI: | 1265105068 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MELVIN | ||||||||
| FirstName: | JASON | ||||||||
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| Credential: | DNP, CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 340 COBALT LN | ||||||||
| Address2: | |||||||||
| City: | MIRAMAR BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 325505301 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 340 BOATNER RD | ||||||||
| Address2: | |||||||||
| City: | EGLIN AFB | ||||||||
| State: | FL | ||||||||
| PostalCode: | 325421391 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8508838600 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/28/2021 | ||||||||
| LastUpdateDate: | 07/28/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 07/28/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 11013481 | FL | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
No ID Information.